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OB GYN > menopause and hormones > Flashcards

menopause and hormones Flashcards

1
Q

average age of menopause

A

51.5

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2
Q

definition of menopause

A

1 year of amenorrhea

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3
Q

definition of POI

A

menopause <40

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4
Q

etiology of POI

A
  • genetic: turners, fragile X, mosaicism XO/XX
  • iatrogenic - chemo, rad, surg
  • autoimmune
  • infectious
  • metabolic - galactossemia
  • most often idiopathic
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5
Q

perimenopause definition

A

4-5 years of hormone fluctations prior to menopause + 1 year after FMP

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6
Q

What are inhibins

A

excreted by ovary, inhibit hypothalamic secretion of GnRH

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7
Q

HPO axis

A

hypoT secretes GnRH

pituitary secretes LH and FSH

ovary secretes E + P, neg feedback to both above

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8
Q

types of estrogens

A

estradiol (E2) - from follicle

estrone (E1) - from metabolism of estradiol and peripherally made from adrenal precursors

Estriol (E3)

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9
Q

measure of ovarian reserve

A

AMH

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10
Q

estrogen receptor types

A

alpha - mostly in reproductive organs & breast, also in liver, bone adipose, brain

beta - more in colon, vasc, lung, bladder, brain

both in ovary, CNS, cardiovasc

estradiol binds both

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11
Q

SERMS

A

bind only alpha or beta estrogen receptors

eg tamoxifen, clomiphene

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12
Q

physiology in late reproductive phase

A
  • menstrual cycle changes
  • FSH + E2 variable
  • AMH low
  • inhibin B low
  • day 3 FSH > 10
  • cycles shorten as FSH recruits follicles earlier
  • symptoms from FSH + temp higher E (sore breast, anovulation, bloating, irritability, menorrhagia, fibroid growth, nausea)
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13
Q

peri-menopause symptoms + physiology

A
  • erratic cycles, then stop
  • heavy bleed or post-menopausal: workup
  • more anovulation
  • E and P lower
  • E esp lower 6 months before LMP
  • still use contraception
  • testosterone same or lower
  • SHBG decreases
  • adrenal hormones decrease
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14
Q

post-meopausal physiology

A
  • high FSH + LH (eventually stabilizes)
  • loss neg feedback, E low
  • estrone dominant E
  • no ovulation
  • no progesterone
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15
Q

signs and symptoms of hypoE

A 
hot flashes + night sweats
vaginal - dry, dysparuenia, pruritis
sleep
urinary freq, urgency, stress
sex dysfunction
depression, anxiety, irritability
memory loss
joint pain
weight gain
headaches
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16
Q

physiology of hot flashes

A

narrowed thermoreg centre in ant hypothalamus

body temp rises, vaso dilate to cool

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17
Q

worsens hot flashes

A

smoking, obesity, alcohol, sedentary, genetics, low SES

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18
Q

associated conditions w hot flashes

A

memory, depression, sleep issues

if early onset + freq: cardiovasc risk (increased endothelial reactivity)

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19
Q

differential dx for hot flashes

A

hyperthyroidism
infection, tb
malignancies - blood, pheochromocytoma, insulinoma
meds: nitrates, tamoxifen, aromatase inhib

don’t investigate if 40s-50s, common/normal

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20
Q

physiology / signs of fertility decline

A
  • age 35, rapid after 37
  • increased SA, chromosomal abnormalities
  • day 3 FSH measure egg cohort
  • AMH declines
  • decreased antral follicle cou t
21
Q

vaginal symptoms of menopause

A
  • dry, itch, odour, duspareunia, pain
  • tissues fragile, bleeding
  • pallor, dry, loss of rugae
22
Q

physiology of genitourinary syndrome of menopause

A
  • worsens /w age
  • thinner epithelium
  • more infection from vag + rectal bacteria, lactobacilli decline
  • pH rises
  • vag lubrication decreased
  • less blood flow, elastin, collagen
23
Q

urinary symptoms of aging (not correlated /w menopause)

A

stress, urgency, fre, dysuria, nocturia, incontinence

recurrent UTI - anatomic causes + less E

24
Q

RFs for urinary symptoms

A 
obese
DM
parous
depression
hysterectomy
family hx
25
Q

sleep disorders in aging

A

apnea
RLS
meds - SSRIs
depression/anxiety

hot flashes - trigger awakening early in night, later in night awakening triggers hot flash

26
Q

sleep disorder lined to

A 
chronic illness
fibromylagia
heart disease
mood disorders
work injury
27
Q

tx of sleep issues

A

sleep hygiene
CBT
yoga, acupuncture

estrogen may help
meds

28
Q

tx mood disorders in menopause

A

psychiatry

SSRIs, estrogen may help in addition but not primary

29
Q

osteoporosis definition

A

BMD > 2.5 standard deviations below curve for young adult women

or fragility fracture

30
Q

RFs for osteoporosis

A 
age
hx fractures
fam hx
x-ray shows osteopenia
smoking
low BMI
meds: anti-epileptics, steroids, hormone suppressives, heparin, immunosuppressives, chemo
hyperthyroidism
alcoholism
malabsorption
31
Q

prevention of osteoporosis

A

1000 IU vitamin D for all menopausal women

Ca 1250 mg/day by diet or supplement

32
Q

loss of estrogen effect on bones

A

loss inhibition of bone resorption

33
Q

risk of early menopause

A

MI + CHF increased 2-3x if not replaced until age 51

34
Q

cardiovasc changes in menopause

A
  • LDL rises
  • vasc changes due to lost E + P
  • coagulation: fibrinolytic and pro-coagulation factors increase
  • more vasoconstriction
  • nitric oxide increases, ACE decreases
  • insulin resistance increases
35
Q

causes of sexual dysfunction in menopause

A
  • social, psychologic
  • partner loss, illness, body image, sleep
  • vag atrophy
  • testosterone decreased
36
Q

tx of sex dysfunction

A
  • flibanserin being approved - SSRI to improve desire

- low dose transdermal testosterone - off label, may try if BSO

37
Q

estrogen + dementia

A
  • connection controversial
  • some studies say protective, some say causes cog decline
  • memory change in menopause common
38
Q

exercise in menopause

A

strength/ resistance

aerobic

flexibility/stretch

balance

39
Q

benefits of exercise

A 
sleep
mood
pain
osteoporosis
falls risk
BC risk
CVD
DM
40
Q

Tx for vasomotor symptoms

A
  • CAM: black cohosh + vit E = minimal benefit, soy maybe, hypnosis
  • CBT
  • avoid alcohol + smoking
  • HRT
  • SSRI + SNRI: venlafazine, paroxetine (not if on tamoxifen), fluoxetine, escitalopram (SE: nausea, headache, sexual dysfunction)
  • eszopiclone for night time
  • clonidine
  • gabapentin - causes drowsiness, good for night sweats
41
Q

tx for vaginal dryness

A

lubricants for sex
moisturizers - replens
hyaluronic acid products
local estrogen

42
Q

bone health management

A

ca
vit d
exercise/fall prevention
BMD after 65 or if RFs

meds for osteoporosis

  • HRT if younger
  • bisphosphnates
  • SERMs - raloxifene (spinal #)
  • RANK ligand inhib
  • PTH hormone if severe
43
Q

options for HRT

A
  • estrogen, add P if uterus for endo protection
  • conjugated equine estrogen (premarin), multiple estrogens
  • oral estradiol
  • estradiol in gel or patch
  • local: ring, vag tablets (vagfm), cream
  • progestin: daily - amenorrhea, 10-14 days a month to minimize dose - may menstruate
  • oral progesterone, medroxyprogesterone, norethindrone acetate oral, progestin, IUD
  • or use TSEC: tissue selective estrogen complex, equine estrogens + SERM so no prog needed (no effect on uterus)
  • combo therapies: patch, pills
  • nonsmoking + menstruating perimenopausal can use OCP until age 54 (good cycle control but more E so higher thrombolic risk)
  • progestins alone may help hot flashes
44
Q

indications for HRT

A
  • vasomotor symptoms
  • vaginal atrophy (try local first)
  • 2nd line: osteoporosis preention in symptomatic women or alts causing side effects
45
Q

risks of HRT

A
  • stroke- rare, more if older
  • DVT + PE (oral, 60+, and higher doses)
  • BC in some formulas after 5 years, higher longer used, similar risk as delay childbirth until > 30 or being 20% overweight
  • gall bladder disease risk
  • risk med interventions b/c of bleeding
  • ? CHD if E + P
46
Q

benefits of HRT

A
  • tx of hot flash: reason to rx
  • mood improvement
  • vag symptoms
  • osteoporisis prevention
  • ? sleep
  • ? colorectal cancer
  • not recommended to use FOR CVD, but estrogen alone may benefit in younger
47
Q

duration of HRT

A
  • start within 5 years of menopause
  • tx as long as necessary, re-evaulated periodically, long term may be used if understand the risks
  • benefits > risks usually if under 60 or within 10 years of menopause
  • use local estrogen if vag symptoms only
48
Q

CI to HRT

A 
hx BC or estrogen dep uterine Ca
pregnancy 
CAD/CHF, MI or stroke
hx of VTE or TIA
active liver disease
unexplained vg bleed or high risk endo Ca

OB GYN (22 decks)

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